《NANDA确定的128个护理诊断知识讲解.doc》由会员分享，可在线阅读，更多相关《NANDA确定的128个护理诊断知识讲解.doc（14页珍藏版）》请在taowenge.com淘文阁网|工程机械CAD图纸|机械工程制图|CAD装配图下载|SolidWorks_CaTia_CAD_UG_PROE_设计图分享下载上搜索。
1、Good is good, but better carries it.精益求精，善益求善。NANDA确定的128个护理诊断-NANDA确定的128个护理诊断NANDA通过的以人类反应型态(HumanResPonsePatterns)的分类方法。现将人类反应型态分类方法的128个护理诊断分列如下：一、交换(Exchanging)营养失调：高于机体需要量(AlteredNutrition：MoreThanBodyRequirements)营养失调：低于机体需要量(AlteredNutrition：lessThanBodyRequirements)营养失调：潜在高于机体需要量(AlteredNut
2、rition：PotentialforMoreThanBodyRequirements)有感染的危险(RiskforInfection)有体温改变的危险(RiskforAlteredBodyTemperature)体温过低(Hypothermia)体温过高(Hyperthermia)体温调节无效(IneffectiveThermoregulatlon)反射失调(Dysreflexia)便秘(Constipation)感知性便秘(PerceivedConsttipation)结肠性便秘(ColonicConstipation)腹泻(Diarrhea)大便失禁(BowelInconttinence
3、)排尿异常(AlteredUrinaryElimination)压迫性尿失禁(SiresIncontlnence)反射性尿失禁(ReflexIncontlnence)急迫性尿失禁(UngeIncontlnence)功能性尿失禁(FunctionalIncontlnence)完全性尿失禁(TotalIncontlnencd尿储留(UrinaryRetentron)组织灌注量改变(肾、脑、心肺、胃肠、周围血管)(AlteredTissuePerfuslorl(Renal，Cereral，CardlopulmonaryGastrolntestlnal，Peripheral)体液过多(FluidVol
4、umeExcess)体液不足(FluidVolumeDeficit)体液不足的危险(RiskforFluidVolUmeDeficit)心输出量减少(Deer。A。EdCardlacouPu)气体交换受损(ImnairedGasExc5anse)清理呼吸道无效(IneffectheAirwayClearance)低效性呼吸型态(IneffectiveBreathingPattern)不能维持自主呼吸(InabilitytoSustainSpontaneousVentilation)呼吸机依赖(DysfunctionalVentilatoryWeaningResPonse，DVWR)有受伤的危险
5、(RiskforInjury)有窒息的危险(RiskforSuffocation)有外伤的危险(RiskforTrauma)有误吸的危险(RiskforAspiration)自我防护能力改变(AlteredProtection)组织完整性受损(ImPairedTissueIntegrity)口腔粘膜改变(AlteredOralMucousMembrance)皮肤完整性受损(ImPairedSkinIntegrity)有皮肤完整性受损的危险(RiskforImPairedSkinIntegrity)调节颅内压能力下降(DecreasedAdaPtiveCaPacityIntracranial)精
6、力困扰(EnergyFielddistubance)二、沟通(Communicating)语言沟通障碍(impairedVerbalCommunlcatlon)三、关系(Relating)社会障碍(ImpairedSoialInteratlon)社交孤立(SocialIsolition)有孤立的危险(RiskforLonelines。)角色紊乱(AlteredRolePerformance)父母不称职(AlteredParenting)有父母不称职的危险(RiskforAlteredParenting)有父母亲子依恋改变的危险(RiskforAlteredParent/Infant/Child
7、Att8Chffi6llt)性功能障碍(SexualDysfunction)家庭作用改变(AlteredFamilyProcess)照顾者角色障碍(CaresiverRoleStrain)有照顾者角色障碍的危险(RiskforCaregiverRoleStrain)家庭作用改变：酗酒(AlteredFamilyProcess：Alcoholism)父母角色冲突(ParentalRoleConflict)性生活型态改变(AlteredSexualityPatterns)四、赋予价值(Valuing)精神困扰(SpiritualDistress)增进精神健康：潜能性(PotentialforEnh
8、anceSpiritualWell-Belug)五、选择(Choosing)个人应对无效(IneffctiveIndividualCoping)调节障碍(ImPairedAdjustment)防卫性应对(DefensiveCoping)防卫性否认(IneffectiveDenial)家庭应对无效：失去能力(IneffectiveFamilyCoping：Disabling)家庭应对无效：妥协性(IneffectivFamilyCoping：Compromised)家庭应对：潜能性(FamilyCoPing：PotentialforGrowth)社区应对：潜能性(PotentialforEnha
9、ncedCommunityCoPing)社区应对无效(IneffectiveCommunityCoping)遵守治疗方案无效(个人的)(IneffectiveManagementofTherapeuticRegimen)(Individual)不合作(特定的)(Noncompliance)(Specitfy)遵守治疗方案无效(家庭的)(IneffectiveManagementofTherapeuticRegimen：(Families)遵守治疗方案无效(社区的)(IneffectiveManagementofTherapeuticRegimen：Community)遵守治疗方案有效(个人的)
10、(EffectiveManagementofTherapeuticRegimen：Individual)抉择冲突(特定的)(DecisionalConflict)(Specify)寻求健康行为(特定的)(HealthSeekingBehaviors)(Specity)六、活动(Moving)躯体移动障碍(ImPairedPhysicalMobility)有周围血管神经功能障碍的危险(RiskforPeriPheralNeurovascularDysfunction)有围手术期外伤的危险(RiskforPerloperatlvePositioningInjury)活动无耐力(ActivityIn
11、tolerance)疲乏(Fatigue)有活动无耐力的危险(RiskforActivityIntolerance)睡眠状态紊乱(SleepPatternDisturbance)娱乐活动缺乏(DiversionalActivityDeficit)持家能力障碍(ImpairedHomeMaintenanceManagement)保持健康的能力改变(AlteredHealthMaintenance)进食自理缺陷(FeedingSelfCareDeficit)吞咽障碍(ImpairedSwallowing)母乳喂养无效(IneffectiveBreastFeeding)母乳喂养中断(Interrun
12、tedBreast1ceding)母乳喂养有效(EffectiveBreastfeeding)婴儿吸吮方式无效(IneffectiveInfantFeedingPattern)沐浴/卫生自理缺陷(Bathing/HygieneSelfCareDeficit)穿戴/修饰自理障碍(Dressing/GroomingSelfCareDeficit)入厕自理缺陷(ToiletingSelfCareDeficit)生长发育改变(AlteredGrowthandDevelopment)环境改变应激综合征(RelocationStressSyndrome)有婴幼儿行为紊乱的危险(RiskforDisorga
13、nizedInfantBehavior)婴幼儿行为紊乱(DisorganizedInfantBehavior)增进婴幼儿行为(潜能性)(potentialforDisorganizedInfantganlzedInfantkhavlor)七、感知(Perceiving)自我形象紊乱(BodyImagseDisturbance)自尊紊乱(SolfEsteemdisturbance)长期自我贬低(ChronicLowSelfEsteem)情境性自我贬低(SituationalLowSelfEsteem)自我认同紊乱(PersonalIdentitydisturbance)感知改变(特定的)(视、听
14、、运动、味、触、嗅)(Sensory/PerceptualAlterations)(specify)(Visual，Auditory，Kinesthetlc，Gustatory，Taotile，Olfactory)单侧感觉丧失(UnilateralNeglect)绝望(Honelessness)无能为力(Powerlessness)八、认知(Knowing)知识缺乏(特定的)(KnowledgeDeficit)(Specify)定向力障碍(ImpairedEnvironmentalInterpretation)突发性意识模糊(AcuteConfusion)渐进性意识模糊(ChronicConf
15、usion)思维过程改变(AlteredThoughtProcesses)记忆力障碍(ImPairedMemory)九、感觉(Feeling)疼痛(Pain)慢性疼痛(ChronicPain)功能障碍性悲哀(DysfunctionalCrievins)预感性悲哀(AnticiPatoryCrieving)有暴力行为的危险：对自己或对他人(RiskforViolence：Self-DirectedordrectedatOthers)有自伤的危险(RiskforSelfMutilation)创伤后反应(PostTraumaResponse)强奸创伤综合征(RaPeTraumaSyndrome)强奸创伤综合征：复合性反应(RepeTraumaSyndrome:CompoundReaction)强奸创伤综合征：沉默性反应(RapeTraumaSyndrome：Silent)焦虑(Anxiety)恐惧(Fear)-